Creating a Just Culture: The Ottawa Hospital's experience.

We describe The Ottawa Hospital's (TOH) journey to create a Just Culture. We will describe the concept of a Just Culture, why TOH initiated this transformation, how TOH went about creating the Just Culture, and some of its early impacts. Following two events that called into question our hospital's safety culture, the hospital leadership adopted a deliberate and methodical organization-wide approach to change.

Cardiovascular Outcomes and All-Cause Mortality in Patients with Obstructive Sleep Apnea and Chronic Obstructive Pulmonary Disease (Overlap Syndrome).

Rationale: The combined impact of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) on cardiovascular outcomes remains controversial.

Objectives: We determined whether the combined presence of COPD and severe OSA defined by the apnea-hypopnea index (AHI) or degree of nocturnal hypoxemia is associated with increased hazards of cardiovascular events and mortality.

Methods: Prospectively collected data from adults with suspected OSA who underwent sleep study between 1994 and 2010 were linked to provincial administrative data to determine a presence of COPD and composite outcome.

Stent-assisted coiling of posterior inferior cerebellar artery aneurysm complicated by arterial avulsion.

Background: Rapid development of new devices and techniques in endovascular neurosurgery allows treatment of complex intracranial vascular lesions. These treatments, however, are not without risk. We report a case of unusual vascular laceration during stent-assisted coiling of a posterior inferior cerebellar artery (PICA) aneurysm.

Development of lupus nephritis in a patient with previous scleroderma renal crisis.

We present a case of scleroderma overlap syndrome with systemic lupus erythematosus (SLE) including complications of both scleroderma renal crisis and lupus nephritis. Our patient was initially diagnosed with undifferentiated connective tissue disease in 1996. A diagnosis of scleroderma was made in 2010 after she developed scleroderma renal crisis.

Underdiagnosis and Overdiagnosis of Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is regarded as one of the leading causes of morbidity and mortality across the world, yet its proper diagnosis remains a challenge. Community-based population studies conducted in North and South America, Europe, Australia, and Asia have revealed that 10% to 12% of adults aged 40 years or older have evidence of persistent airflow limitation on spirometry, but only 20% to 30% of these subjects have been diagnosed with COPD. These studies collectively suggest that approximately 70% of COPD worldwide may be underdiagnosed.

Underdiagnosis and Overdiagnosis of Asthma.

Asthma is diagnosed on the basis of respiratory symptoms of wheeze, cough, chest tightness, and/or dyspnea together with physiologic evidence of variable expiratory airflow limitation. The prevalence of asthma varies widely around the world, ranging from 0.2% to 21.

Piperacillin Population Pharmacokinetics in Critically Ill Adults During Sustained Low-Efficiency Dialysis.

Background: Sustained low-efficiency dialysis (SLED), is increasingly being used in intensive care units (ICUs) but studies informing drug dosing for such patients is lacking.

Objective: To describe the population pharmacokinetics (PKs) of piperacillin/tazobactam in critically ill adults receiving SLED and to provide dosing recommendations.

Methods: This prospective population PK study was conducted in adult ICU patients prescribed piperacillin/tazobactam while receiving SLED; 321 blood samples were obtained from 34 participants during and between approximately 50 SLED treatments for quantification of piperacillin and tazobactam concentrations in plasma.

Commentary on "Regulatory Support Improves Subsequent IRB/REC Approval Rates in Studies Initially Deemed Not Ready for Review: A CTSA Institution's Experience".

In response to researcher concerns a number of initiatives have been developed to support individual researchers seeking ethics review and approval. In this issue, Sonne et al. (2017) outline an example of an intervention to support researchers, which they refer to as a Regulatory Knowledge Support (RKS) service.

Is Ultrasound Useful for Further Evaluation of Homogeneously Hyperattenuating Renal Lesions Detected on CT?

Objective: The purpose of this study was to evaluate the ability of ultrasound (US) to characterize hyperattenuating cysts detected as indeterminate hyperattenuating renal lesions on unenhanced and single phase enhanced CT.

Materials And Methods: A total of 107 consecutive homogeneously hyperattenuating renal lesions underwent gray-scale and Doppler US at our institution between 2010 and 2013. Two radiologists who were unaware of the final diagnosis retrospectively evaluated US images for visibility and diagnosis (simple cyst, intermediate complexity cyst, cystic or solid mass showing internal flow on Doppler US, or indeterminate).

Diagnostic Instability and Reversals of Chronic Obstructive Pulmonary Disease Diagnosis in Individuals with Mild to Moderate Airflow Obstruction.

Rationale: Chronic obstructive pulmonary disease (COPD) is a chronic, progressive disease, and reversal of COPD diagnosis is thought to be uncommon.

Objectives: To determine whether a spirometric diagnosis of mild or moderate COPD is subject to variability and potential error.

Methods: We examined two prospective cohort studies that enrolled subjects with mild to moderate post-bronchodilator airflow obstruction.

Injectable Diphenhydramine Used as Anaesthetic for Wide Local Excision With Flap Closure.

Background: Lidocaine-allergic patients pose a challenge for cutaneous surgical procedures. We present a case of a successful wide local excision with flap closures on the face using topical tetracaine followed by infiltration with 1% diphenhydramine.

Case Summary: An 84-year-old woman, with a lidocaine intolerance, presented to the Mohs surgery clinic for wide local excision of a nodular basal cell carcinoma on her right medial cheek.

A smartphone photogrammetry method for digitizing prosthetic socket interiors.

Background And Aim: Prosthetic CAD/CAM systems require accurate 3D limb models; however, difficulties arise when working from the person's socket since current 3D scanners have difficulties scanning socket interiors. While dedicated scanners exist, they are expensive and the cost may be prohibitive for a limited number of scans per year. A low-cost and accessible photogrammetry method for socket interior digitization is proposed, using a smartphone camera and cloud-based photogrammetry services.

Clear Cell Urothelial Carcinoma.

Clear cell urothelial carcinoma (CCUC) is a rare variant of urothelial carcinoma (UC) and its clinical significance has not been well elucidated. Consecutive cases of UC over a period of 5 years were reviewed. Histopathological tumor parameters, including the proportion of tumor cells with clear cell change, and patient outcomes were recorded.

The Case for Requiring Graphic Warning Labels on Smokeless Tobacco Product Packages.

On November 10, 2015, the U.S. Food and Drug Administration approved, for the first time, the sale of smokeless tobacco products authorized under the new premarket tobacco application pathway.

Solid Renal Cell Carcinoma Measuring Water Attenuation (-10 to 20 HU) on Unenhanced CT.

Objective: The objectives of this study were to evaluate the incidence of solid renal cell carcinoma (RCC) with attenuation similar to that of water (-10 to 20 HU) on unenhanced CT and to examine imaging features that can allow RCC to be differentiated from simple cysts.

Materials And Methods: We performed an enriched quantitative and qualitative retrospective analysis of consecutive patients who underwent unenhanced CT before resection of solid (noncystic and nonnecrotic) renal masses measuring < 5 cm from 2008 to 2013. In all, 93 patients with 96 tumors (55 clear cell, 27 papillary, and 14 chromophobe) were evaluated with unenhanced CT.

A systematic review highlights a knowledge gap regarding the effectiveness of health-related training programs in journalology.

Objectives: To investigate whether training in writing for scholarly publication, journal editing, or manuscript peer review effectively improves educational outcomes related to the quality of health research reporting.

Study Design And Setting: We searched MEDLINE, Embase, ERIC, PsycINFO, and the Cochrane Library for comparative studies of formalized, a priori-developed training programs in writing for scholarly publication, journal editing, or manuscript peer review. Comparators included the following: (1) before and after administration of a training program, (2) between two or more training programs, or (3) between a training program and any other (or no) intervention(s).

Unenhanced CT for the diagnosis of minimal-fat renal angiomyolipoma.

Objective: Minimal-fat angiomyolipoma resembles renal cell carcinoma (RCC) on imaging. The purpose of this study was to evaluate the diagnostic accuracy of unenhanced CT to diagnose minimal-fat angiomyolipoma.

Materials And Methods: Consecutive patients who underwent unenhanced CT before resection of a solid renal mass from 2002 to 2012 were included in this study.